1388 THE ENTEROIDEA GROUP OF TROPICAL FEVERS 



poisoning, or the signs of an acuie nephritis. Lastly, the type in 

 which haemorrhages begin early and are persistent is often spoken 

 of as the hgemorrhagic type. 



One curious form may be just mentioned, as, for example, the 

 spleno-typhoid, in which the spleen is very markedly enlarged, 

 without signs of malaria or relapsing fever. 



Complications and SequelatJ. — The most important complication 

 is malaria, but dengue and certain unclassified fevers of intestinal 

 origin are occasionally met with during the first week, and com- 

 plicate the diagnosis. Bedsores and boils are not infrequent 

 complications, and loss of hair is a frequent sequel. Venous throm- 

 bosis in the femoral vein is a frequent complication, and infarction 

 may occur in various organs. Arterial thrombosis is much rarer. 

 Acute ascending myelitis is noted, while joints may be attacked, 

 giving rise to a typhoidal arthritis, and the spine to a typhoidal 

 spondylitis. Periostitis of various bones is not rare. Inflamma- 

 tion of the thyroid gland may also occur. Haemorrhage and per- 

 foration have been noted. Iritis, orbital cellulitis, and purulent 

 choroiditis have been recorded as due to typhoid fever, but purulent 

 otitis media and mastoiditis, described as associated with typhoid - 

 fever, are generally due to other causes than the typhoid bacilli. 

 Appendicitis and meningitis may also occur. 



Relapse. — One of the most important sequels to an attack of 

 enteric fever is the relapse which may occur at any time during 

 the three or four weeks following the fall of temperature to normal. 

 It usually resembles an ordinary attack of typhoid fever. 



Diagnosis. — The diagnosis of enteric in typical cases is not 

 difficult, being based principally on the slow onset of the fever, the 

 enlargement of the spleen, the presence of roseola at the beginning 

 of the second week, the apathetic appearance of the patient, the 

 leucopenia. Every medical man, however, practising in the tropics 

 has noticed that enteric fever there, much more frequently than in 

 temperate climates, presents an atypical course. The temperature 

 chart may be very irregular, sometimes of a well-marked remittent 

 or intermittent type (Fig. 659) ; the enlargement of the spleen may 

 be absent during the whole course of the disease, or in other cases 

 it may be much more enlarged and harder than is usually the 

 case; roseola, invisible, of course, in natives, may be absent in 

 Europeans, while at times these may present a profuse rash. In 

 a few cases some of the peculiarities met with, especially the very 

 irregular type of temperature, are explained by the presence of 

 two infections — typhoid and malaria. Individuals who have had 

 an attack of malaria may harbour in their spleen Laveran's 

 parasites for a long time without any symptoms, but as soon as 

 the resistance of the organism is diminished by any cause like a 

 chill, a disorder in dietetics, or the onset of some disease, an attack 

 of malarial fever ensues. When these malarial carriers develop 

 enteric, the malarial infestion breaks out again, and probably 

 modifies the course of the temperature. It must be admitted, how-; 



